- Educate providers about appropriate use of the
hepatitis B vaccine, especially in newborns and adolescents.
- Educate the general public about hepatitis B risk
factors, hepatitis B vaccine, and prevention of hepatitis B
transmission.
- Educate health care providers and laboratories to
report hepatitis B surface antigen (HBsAg) positive or hepatitis B
core IgM (HBc IgM) positive patients to the HIV/AIDS/STD Program at
the West Virginia Bureau for Public Health (WVBPH) within 24 hours.
- Within 24 hours of receiving a report of an HBsAg
or HBcAb IgM positive patient, the HIV/AIDS/STD Program will assign
the newly reported case to the appropriate Disease Investigation
Specialist (DIS). Women of childbearing age who have previously been
reported as HBsAg positive will be referred to the West Virginia
Immunization Program to determine if they are pregnant. Within 24
hours of assignment, the DIS and the local health department should
negotiate shared responsibilities to accomplish the following:
- Contact the physician to determine if the
patient meets the case definition for acute hepatitis B.
- Ask if the patient is pregnant. If yes, notify
the Perinatal Hepatitis B Coordinator at the Immunization Program
immediately (1-800-642-3634).
- If the patient meets the case definition for acute
hepatitis B infection, complete a reportable disease case report
card and the CDC hepatitis form, attach laboratory studies
(including hepatitis A virus immunoglobulin M (HAV IgM), alanine
transferase (ALT), HBsAg, HBcAb IgM, and hepatitis C testing
results, if available), and send all documents to the HIV/AIDS/STD
Program.
- Investigate forward (to prevent disease in
contacts):
- Identify all sexual contacts and
determine the date of last contact with the source patient. If the
last contact with the patient is within 14 days, and the vaccine or
immune status is not known:
- Submit a blood sample from the contact(s) to
the West Virginia Office of Laboratory Services (OLS) for a
hepatitis B screen.
- Administer hepatitis B immunoglobulin (HBIG)
and the first dose of hepatitis B vaccine to the contact(s).
- If hepatitis serologies are positive, stop
the vaccination series and refer the patient for medical care. If
serologies are negative, complete the full immunization series.
- Complete the tracking form and submit it to
the HIV/AIDS/STD Program.
- Identify all needle sharing contacts and
determine the last contact with the source patient. If the date of
the last needle sharing event with the source patient is within
seven days, and vaccine and immune status are not known:
- Submit a blood sample from the contact(s) to
the OLS for a hepatitis B screen.
- Administer HBIG as well as the first dose of
hepatitis B vaccine to the contact(s).
- If hepatitis serologies are positive, stop
the vaccination series and refer the patient for medical care. If
serologies are negative, complete the full immunization series.
- Complete the tracking form and submit it to
the HIV/AIDS/STD Program.
- HBIG must be administered within a week after
the last needle sharing event with the source patient.
- Identify all household contacts and
determine if they have had any blood exposure to the source patient
(e.g. shared razor, etc.). If a blood exposure is identified within
14 days:
- Draw a blood sample from the contact(s) and
send it to the OLS for a hepatitis B screen.
- Administer HBIG and the first dose of
hepatitis B vaccine to the contact(s).
- If hepatitis serologies are positive, stop
the vaccination series and refer the patient for medical care. If
serologies are negative, complete the full immunization series.
- Complete the tracking form and submit it to
the HIV/AIDS/STD Program.
- If the household contact is an infant and the
mother or primary care giver has acute hepatitis B infection,
administer HBIG and hepatitis B vaccine to the infant immediately.
Complete the series for the infant. For partially or fully
immunized infants, contact IDEP for an individualized
recommendation.
- If the source patient is or becomes a
hepatitis B carrier, all household contacts should receive the
hepatitis B vaccine series.
- If the index patient is pregnant, the
local health department should negotiate with the physicians and the
West Virginia Immunization Program Hepatitis B Perinatal Coordinator
to assure that all of the following occur:
- Before birth:
- The mother should be educated about
hepatitis B.
- HBIG and a dose of hepatitis B vaccine
should be shipped to the birthing facility in advance of the due
date.
- Physician's orders should be written to
assure that HBIG and the first dose of hepatitis B vaccine will
be administered within 12 hours of birth of the infant.
- A pediatric immunization provider should be
identified.
- The local health department and the
Immunization Program should be notified when the child is
delivered.
- At birth:
- Assure that HBIG and the first dose of
hepatitis B vaccine are given and the immunization record is
reported to the West Virginia Statewide Immunization Information
System (WVSIIS).
- Premature infants born to HBsAg-positive
mothers should receive hepatitis B vaccine and HBIG beginning at
or shortly after birth.
- Again, assure that the child will be
followed up by an immunization provider.
- After birth:
- Assure that the infant receives doses
number two and three on schedule and that the immunization
record is reported to the WVSIIS.
- Assure that HBsAg and HBsAb (check both
"perinatal" and "postvaccination" on the
form for OLS) are drawn three to nine months after the third
dose of hepatitis B vaccine (i.e. at nine to 15 months of age)
and results are reported to the Immunization Program. If HBsAg
is not present and anti-HBs antibody is present, children can be
considered to be protected.
- If HBsAb and HBsAg are negative, assure
repetition of the series.
- If HBsAg is positive, refer the infant for
medical care.
- For cases with acute hepatitis B,
investigate backward, as follows:
- Using a calendar, determine the incubation
period for the case. The incubation period is six weeks to six
months prior to the date of onset.
- Collect information on all possible risk
factors during the incubation period, and record it on the
reportable disease case report card and the CDC hepatitis form.
Discuss any unusual risk factors or clustering of risk factors with
the West Virginia Infectious Disease Epidemiology Program (IDEP).
Risk factors and possible risk factors include:
- Contact with a person with suspected or
confirmed HBV infection;
- Employment involving contact with human
blood;
- Receipt of blood transfusion or blood
products;
- Dialysis or kidney transplant patient;
- Injecting drug use;
- Number of different male sexual partners;
- Number of different female sexual partners;
- Hospitalization and/or surgery;
- Intravenous infusions or injections received
in outpatient settings;
- Residence in a long term care facility (e.g.
nursing home);
- Dental work/oral surgery;
- Accupuncture/tattooing/body piercing; and
- Puncture with a needle or other object
contaminated with blood.
- Investigate vaccination history and record as
part of the investigation, including:
- Number of vaccine doses, dates(s) of
vaccination, and post-vaccination test results, if available, and
- Missed opportunities for hepatitis B
vacination, including:
- Household or sex contact with an HBV-infected
person;
- Ever in a correctional facility;
- Ever treated for a sexually transmitted
disease; or
- Ever in treatment for injecting drug use.
- For patients with chronic hepatitis B, record all
action taken on the reportable disease case report card and submit it
with copies of all lab tests to the HIV/AIDS/STD Program.
- For patients with acute hepatitis B, record all
action taken on the reportable disease case report card, and submit it
with copies of all lab tests and the completed CDC supplemental form
to the HIV/AIDS/STD Program.
- Reduce the incidence of hepatitis B by:
- Assuring full hepatitis B immunization of all
infants.
- Assuring "catch-up" hepatitis B
immunization of all adolescents at the adolescent visit.
- Assuring full hepatitis B immunization of
high-risk individuals to include:
- Sexually active adolescents and adults
(including adolescents in STD clinics);
- Household contacts and sexual partners of HBV
carriers;
- Health care personnel and those who have
occupational exposure to blood;
- Residents and staff of institutions for the
developmentally disabled;
- Hemodialysis patients;
- Recipients of certain blood products;
- International travelers;
- Injection drug users; and
- Inmates in long term correctional facilities.
- Reduce the incidence of hepatitis B through
community education and programs to prevent drug use and sharing of
needles.
- Prevent nosocomial transmission of hepatitis B
through effective infection control measures.
- Prevent transmission of hepatitis B through
screening of blood and organ donors.
- Identify and investigate community-based and
nosocomial outbreaks of hepatitis B in a timely fashion so that
appropriate control measures can be applied.
- Reduce transmission from persons with hepatitis B
infection including:
- Perinatal transmission; and
- Transmission to household, sexual, and
drug-using partners.
- Determine the incidence of acute hepatitis B in
West Virginia.
- Determine the risk factors associated with acute
and chronic hepatitis B in West Virginia.
- Determine the demographic characteristics of
persons with acute and chronic hepatitis B.
- Distinguish between failure to immunize
(preventable cases) versus failure of vaccine (non-preventable cases)
among the reason(s) for continued occurrence of hepatitis B.
- Detect outbreaks, clusters, or unusual patterns
of transmission of hepatitis B.
- Estimate the annual number of newly diagnosed
chronic cases of hepatitis B.
Hepatitis B is a vaccine preventable disease. When
the vaccine was first introduced in 1982, it was recommended for high-risk
groups (e.g. men who have sex with men, persons with multiple sexual
partners or a history of a sexually transmitted disease, injection drug
users, health care workers or persons with occupational exposure to blood,
etc.). However, the number of cases of hepatitis B continued to increase
after the vaccine was introduced. In 1991, universal infant immunization
was instituted, followed by a recommendation for catch-up vaccination of
adolescents in 1996. At this time, the incidence of hepatitis B is
declining.
Chronic hepatitis B virus infection is associated with the development
of hepatocellular carcinoma. In Southeast Asia, HBV infection is endemic
and hepatocellular carcinoma is a common cause of cancer death. After
launching a nationwide vaccination program in Taiwan to control hepatitis
B, the HBsAg carrier rate in children declined from about 10% to 1% within
10 years of implementation. Concurrently, the average annual incidence of
hepatocellular carcinoma per 100,000 children six to 14 years of age
declined from 0.70 between 1981 and 1986; to 0.57 between 1986 and 1990;
and to 0.36 between 1990 and 1994. The incidence of hepatocellular
carcinoma in children six to nine years of age declined from 0.52 per
100,000 for those born between 1974 and 1984 to 0.13 per 100,000 for those
born between 1984 and 1986. This was the first demonstration that mass
vaccination could reduce the incidence of a specific cancer in humans.
According to the CDC, one of 20 persons in the U.S. has been infected
with hepatitis B virus during their lifetime (about 12.5 million); one of
200 persons has chronic (lifelong) infection with hepatitis B virus (about
1.25 million); and 4,000 to 5,000 persons die each year from hepatitis
B-related chronic liver disease (cirrhosis, liver cancer).
In the United States, children become infected with HBV through a
variety of means. The risk of perinatal HBV infection among infants born
to HBV-infected mothers ranges from 10% to 85% depending on each mother’s
hepatitis B e antigen (HBeAg) status. Infants who become infected
by perinatal transmission have a 90% risk of chronic infection, and up to
25% will die of chronic liver disease as adults. Even when not infected
during the perinatal period, children of HBV-infected mothers remain at
high risk of acquiring chronic HBV infection by person-to-person
horizontal transmission during the first five years of life. More than 90%
of these infections can be prevented if HBsAg positive mothers are
identified so that their infants can receive hepatitis B vaccine and
hepatitis B immune globulin (HBIG) soon after birth.
Signs and Symptoms of Acute Disease
Typical symptoms include tiredness, headache, loss
of appetite, nausea, vomiting, fever, and chills with onset three to 10
days prior to jaundice. Right upper quadrant pain is common. Urine may
become dark, and stools may become clay-colored. The hallmark of the
disease is jaundice (yellow color of the skin and sclera). Infants and
children are usually asymptomatic, and an estimated 50% of adults with
acute HBV are asymptomatic.
Fulminant hepatitis occurs in very few patients and
is usually fatal. Duration of illness is usually several weeks, with
symptoms occasionally persisting beyond three to four months.
Signs and Symptoms of Chronic Infection
Ninety to ninety-four percent of adults with acute
HBV will develop protective antibodies within six months of the infection.
A small proportion (6-10%) of adult patients with acute HBV will develop
chronic infection. Most persons with chronic infection will not have
symptoms but will continue to be infectious. Complications of chronic
hepatitis B infection may include cirrhosis and hepatocellular carcinoma.
HBV is a small double-stranded DNA virus. The outer
protein coat contains the hepatitis B surface antigen.
This virus is found only in humans. Chimpanzees are
susceptible, but an animal reservoir in nature has not been identified.
In the United States, the most common risk factor
for transmission of HBV is sexual contact with an infected person;
however, the greatest risk for development of chronic infection is through
perinatal transmission. The hepatitis B virus is also transmitted
by parenteral or mucosal exposure to body fluids containing the virus.
Breaks in the skin, such as scratches, abrasions, and burns, may serve as
routes for the virus to enter the body.
The virus can be found in blood, body fluids (e.g. wound exudates),
semen, cervical fluid, and saliva of persons who are HBsAg positive. Blood
and serous fluids have the highest concentration of virus, and
saliva the lowest.
Person-to-person transmission may occur in household settings. In these
settings, non-sexual transmission occurs predominantly from child to
child, and young children are at highest risk. The precise mechanism for
child to child transmission is not known; however, frequent personal
contact between non-intact skin or mucous membranes with blood containing
secretions or, perhaps, saliva, are possible mechanisms. Transmission from
sharing inanimate objects may also occur because HBV can survive at
ambient temperature for one week or longer.
The incubation period is usually 45 to 180 days,
with an average of 60 to 90 days. Time to detection of HBsAg can be as
short as two weeks or as long as six to nine months, depending on inoculum,
host factors, and other variables.
All persons who are HBsAg positive are potentially
infectious. The presence of HBeAg is associated with a very high level of
infectivity.
Clinical Description
An acute illness with: a) discrete onset of symptoms, and b) jaundice
or elevated serum aminotransferase levels.
Laboratory Criteria for Diagnosis
- IgM antibody to hepatitis B core antigen (anti-HBc) positive or
hepatitis B surface antigen (HbsAg) positive.
- IgM anti-HAV negative (if done).
Case Classification
Confirmed: a case that meets the clinical case definition and is
laboratory confirmed.
Comments
Persons who have chronic hepatitis or persons identified as HBsAg
positive should not be reported as having acute viral hepatitis unless
they have evidence of an acute illness compatible with viral hepatitis
(with the exception of perinatal hepatitis B infection).
Delta hepatitis is not a nationally notifiable disease.
Case
Definition for Perinatal HBV Infection
Clinical Description
Perinatal HBV infection in a newborn can range from asymptomatic to
fulminant hepatitis.
Laboratory Criterion for Diagnosis
Hepatitis B surface antigen (HBsAg) positive.
Case Classification
Confirmed: HBsAg positivity in any infant >1 month old to 24
months old who was born in the United States or in U.S. territories to an
HBsAg-positive mother.
The table below is adapted from Mandell (Principles
and Practice of Infectious Diseases, Fifth Edition). It is a quick guide
to interpretation of hepatitis B serologies. It is important to
recognize that unusual or inconsistent serologies are frequently reported.
If in doubt about the patient diagnosis based on the laboratory results,
it is often useful to repeat the testing.
|
Stage of Infection |
HBsAg |
Anti-
HBsAg |
IgG
Anti-HBc |
IgM
Anti-HBc |
HBeAg |
Anti-
HBeAg |
|
Late incubation period of hepatitis B (person is
infectious but symptoms have not yet developed) |
+ |
- |
- |
- |
+/- |
- |
|
Acute hepatitis B |
+ |
- |
+ |
+ |
+ |
- |
|
Chronic HBV (sometimes called a healthy carrier
since virus is not replicating at a rapid rate) |
+ |
- |
+ |
+/- |
- |
+ |
|
Chronic HBV (positive HBeAg indicates higher degree
of infectivity) |
+ |
- |
+ |
+/- |
+ |
- |
|
Recent HBV infection |
- |
+ |
+ |
+/- |
- |
+ |
|
Remote HBV infection |
- |
+/- |
+/- |
- |
- |
- |
|
Recent HBV vaccination |
- |
+ |
- |
- |
- |
- |
To send specimens to the OLS, collect the blood in a
red top tube or a red and gray striped tube. Complete the hepatitis form
and enclose it with the specimen. OLS offers three choices for testing:
- "Perinatal" will give HBsAg results.
- "Screen" will give HBsAg, HBc Ab total. Other tests will
be run if either or both of the screen markers are positive. Other
markers possible are: IgM to HBc, antiHBsAg, confirmation of HBsAg.
- "Postvaccine" will give anti-HBsAg or antibody to HBsAg.
To get HBsAg and anti-HBsAg, check "perinatal" and "postvaccination."
Hepatitis B vaccine is a very safe and effective
vaccine for prevention of hepatitis B, and it is recommended for all
babies, for adolescents who have not already had the vaccine, and for
people who are at risk for hepatitis B:
- Babies who are born to a mother who is HBsAg positive;
- People who have a job that involves contact with blood and blood
products;
- Injection drug users;
- Sexually active persons who have had more than one partner in the
last six months or who have a sexually transmitted disease;
- Sexually active men who have sex with men;
- Household contacts and sexual partners of persons who are
chronically HBsAg-positive;
- Residents and staff of institutions for developmentally disabled
persons;
- Staff of nonresidential child care and school programs for
developmentally disabled persons if the program is attended by a known
HBsAg-positive person;
- Patients undergoing hemodialysis;
- Patients with bleeding disorders who receive clotting factor
concentrates;
- Members of households with adoptees who are HBsAg-positive;
- International travelers to areas in which HBV infection is of high
or intermediate endemicity;
- Inmates of juvenile detention and other correctional facilities.
Patients should check with their doctor about
treatment for chronic hepatitis B. No specific therapy for acute HBV
infection is available. In chronically infected adults, interferon alpha
has been demonstrated to induce a long-term remission in 25% to 40% of
treated patients. The drug has been less effective for chronic infections
acquired during early childhood. Lamivudine is also licensed for treatment
of chronic HBV infection in adults, but no data are available for use in
children.
- The proportion of acute cases with complete risk
factor information.
- The proportion of acute cases with complete demographic data.
- The proportion of pregnant mothers for whom hepatitis B surface
antigen status is known.
- The proportion of infants born to hepatitis B surface antigen
positive mothers who receive at least three doses of hepatitis B
vaccine before seven months of age.
- The proportion of infants born to HBsAg positive mothers who have
blood drawn for anti-HBsAg and HBsAg.
- The number of household, sexual contact, and needle sharing
contacts identified per case.
- The proportion of contacts of acute and previously unreported
chronic cases that have complete information on the hepatitis B
immunization status or missed opportunities.
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